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:Herpes Viruses

Viruses causing latent


infections
Human Herpes Viruses
The herpes viruses are a diverse group of
large DNA viruses that share:
• A common virion morphology
• A basic mode of replication
• The capacity to establish latent and
recurrent infections
The human herpes viruses are grouped into three sub-families on
, the basis of difference in viral characteristics( genome structure
tissue tropism, cytopathogenicity, site of latent infection) as
.well as the pathogenesis of the disease and disease presentation
Human Herpes Viruses
α Group
•Herpes simplex type 1 and 2-Skin lesions and other
diseases
•Varicella-Zoster virus- varicella and Zoster

β Group
•Cytomegalovirus- Cytomegalic inclusion disease (CID),
disseminated diseases in immunocompromised patients
•Herpes type 6-Roseola infantum/exantema subitum
•Herpes virus 7-?

γ Group
•Epstein Barr Virus-Infectious mononucleosis, BL, NPC
•Herpes virus 8- kaposi’s sarcoma
Unique Features of Herpesvirus
 Herpesviruses have large, enveloped icosadeltahedral
capsids containing double-stranded DNA genomes
 Herpesviruses encode many proteins that regulate
messenger RNA and DNA synthesis and the shutoff of the
host cell DNA, RNA, and protein synthesis.
 Herpesviruses encode enzymes (DNA polymerase) promote
viral DNA replication and that are good targets for antiviral
drugs.
 DNA replication and assembly occur in the nucleus; virus
buds from nuclear membrane and is released by exocytosis
and cell lysis.
 Herpesviruses can cause lytic, persistent, latent/recrrent,
and for EBV, immortalizing infections.
 Herpesviruses are ubiquitous*. Cell-mediated immunity is
required for control
Properties Distinguishing the Herpesviruses

Subfamily Virus Primary Target Site of Means of Spread


Cell Latancy

Alphaherpesvirinae
Human Herpes simplex Mucoepithelial Neuron Close contact
herpesvirus 1 type 1 cells
Human Herpes simplex Mucoepithelial Neuron Close contact
herpesvirus 2 type 2 cells (sexually
transmitted
disease)
Human Varicella-zoster Mucoepithelial Neuron Respiratory and
herpesvirus 3 cells close contact
Properties Distinguishing the Herpesviruses- cont.
Subfamily Virus Primary Target Site of Latancy Means of Spread
Cell

Betaherpesvirinae
Human Cytomegalovirus Monocyte, Monocyte Close contact
herpesvirus 5 lymphocyte lymphocyte, transfusions,
and stromal cells tissue transplant,
epithelial of BM and congenital
cells and?
Human Herpes T cells and T cells and Respiratory and
herpesvirus 6 lymphotropic monocyte, monocytes close contact ?
lymphocyte and?
and epithelial
cells
?
Human Human T cells and ? T cells and ?
herpesvirus 7 herpesvirus 7
Gammaherpesvirinae
Human Epstein-Barr virus B cells and B cell Saliva (kissing
herpesvirus 4 epithelial disease
cells
Structure of Herpes Virus Particle
Electron Micrograph (A) and General
Structure (B) of the Herpesviruses

capsomers 162
Herpesviruses Genomes
size

kbp 125

kbp 152

kbp 186

kbp 229

kbp 162
HS/HveC/HveA
(Nectin1a/ TnfR)
Coordinated and regulated transcription

Trans-
Shut off of Golgi
cellular
network
macromolecule
synthesis
Herpesvirus egress

Figure 72-10 Diagram of pathways of egress. HSV capsids bud through the inner nuclear membrane, forming an enveloped virion particle.
Egress of the virions from the host cell may occur by either of two general pathways. A: The envelope fuses with the outer nuclear membrane,
de-enveloping the capsid and releasing it into the cytoplasm. The capsid then buds into the Golgi apparatus, forming an enveloped virion,
which is transported to the surface by vesicular transport. B: The virion particle buds through the outer nuclear membrane and is transported
by vesicular movement through the Golgi apparatus to the exterior of the cell. (From Fields Virology, 4th ed, Knipe & Howley, eds, Lippincott
Williams & Wilkins, 2001, Fig. 72-10)
Herpes Virus Gene Products
Modulate the Immune Response
1. Viral inhibition of humoral immunity
(complement and antibodies)
2. Viral interference with interferon
3. Viral cytokines and cytokine receptors
4. Viral interference with MHC functions
5. Viral inhibitors of apoptosis
Virokines
Virus Virokine Host function Mechanism

Herpes simplex gE-gI Antibody-mediated Binds Fc of IgG, preventing complement-


Cytolysis mediated cytolysis
C-1 Complement Binds C3b, inhibiting alternative and
classical pathways
Cytomegalovirus UL18 Cytotoxic T cells Homolog of class I MHC, binds b-
microglobulin, preventing translocation to
cell surface
UL144 TNFR TNFR homolog, unknown function

MC54 vIL-18BP. Binds IL-18, Inhibits IL-18 induced IF-J


production
US28 US28 binds cc chemokines

EB Virus BCRF1 Cytokine, cytotoxic T- IL-10 homolog inhibits cytokine synthesis


Cell- suppressing Tc cells and stimulating B
cells
BARF CSF-1R Binds CSF-1
Herpes Simplex Type 1

Herpes Simplex Type 2

Oral or genital herpes and other diseases


Epidemiology of HSV Infection
Disease/Viral Factors
 Virus causes lifelong infection
 Recurrent disease is source of contagion
 Virus may cause asymptomatic shedding

Transmission*
 Virus is transmitted in saliva*, in vaginal secretions, and by
contact with lesion fluid (MMMM)
 Virus is transmitted orally and sexually and by placement
into eyes and breaks in skin
 HSV-1 is generally transmitted orally; HSV-2 is generally
transmitted sexually
Disease Mechanisms for HSV
 Disease is initiated by direct contact and depends on
infected tissue (e.g., oral, genital, brain).
 Virus causes direct cytopathology (several mechanisms
 Cell-mediated immunopathology contributes to symptom
 Virus blocks IF action and MHCI Ag presentation ( TAP)
 Virus avoids antibody by cell-to-cell spread (syncytia) .
 Virus established latency in neurons (hides from immune
response).
 Virus reactivated from latency by stress or immune
suppression.
 Cell-mediated immunity is required for resolution with
limited role for antibody.
HSV Latency and Reactivation

Retrograde
transport
Vp26+ Vp5
dynein +
dynactin

Anterograde
transport

Vp5, Vp16
Us11 and
.Kinesin assoc
HSV1 and HSV2 latency
Neurons Offer Certain Unique Advantages

 Express no MHC antigens, shielded from lysis by


cytotoxic T lymphocytes. Because the latent viral
genome express no protein, also safe from lysis by
antibody plus complement or ADCC.

 Neurons do not divide, the virus has no need to


divide to maintain a fixed number of copies per cell.

 The axon provides a direct pathway to the


periphery, to susceptible epidermal cells.
HSV 1-2 Latency and Reactivation
 Productive infection in epithelial cells of skin and mucous membranes

 Latent in cranial or spinal sensory ganglia (trigeminel ganglion, sacral ganglion)

 Reactivation caused by stimuli, such as “stress”, ultraviolet light, fever, nerve


injury or immunosuppression

 Latent in neurons - 10 –100 copies of viral genome, nonintegrated circular,


extended concatamers. Cellular proteins bind viral DNA and regulate latency

 No standard mRNAs are transcribed. Expression of overlapping non polyadenylated


antisense RNA transcipts (latency associated transcripts, LATs), the size of 8,5,
2 and 1.5 Kb. The 2 and 1.5 Kb transcripts are more abundant.

 The 2 Kb LAT is partially complementary in sequence to the mRNA for a key


regulatory protein, required for transactivation (ICP0).

 The role of the LATs in the establishment and maintenance of latent state is not
known. LATs regulate the viral genome and interfere with the normal activities of
the infected host cell. Stable expression of the abundant LATS in neurons inhibits
viral replication and production of immediate early products. Viral mutants that are
unable to express LATs are reactivation deficient. Recent studies indicate that
LATs inhibit cell death mechanisms and modulate viral chromatin structure.
The Latency Associated Transcripts of
Herpes Simplex Virus Type 1
Clinical Manifestations

HSV is involved in a variety of clinical manifestations which


;includes
Acute gingivostomatitis. 1
(Herpes Labialis )cold sore. 2
Ocular Herpes. 3
Herpes Genitalis. 4
Other forms of cutaneous herpes. 5
Meningitis. 7
Encephalitis. 8
Neonatal herpes. 9
Disease
Syndromes of
HSV
Primary Herpes Gingivostomatitis
Genital
Herpes
Clinical Course of Genital Herpes Infection
Virus shedding
PRIMARY
Herpes Simplex Encephalitis
Herpetic Whitlow

Cold Sore of
Recurrent Herpes
Labialis
Diseases Produced by Herpes Simplex
Virus
Disease Primary (P) or Age Frequency Severity Type
recurrent (R)
Gingivostomatis P Young children Common Mild 1
Pharyngotonsillitis P Adults Common Mild 2<1
Herpes labialis R Any Common Mild 2<1
Genital herpes P,R >15years Common Mild/moderate 2>1

Keratoconjunctivitis P,R Any Common Mild/moderate 1

Skin infection* P,R Any Rare Mild/moderate 1,2

Encephalitis P,R Any Rare Severe 2<1


Neonatal herpes P Newborn Rare Severe 1<2
Disseminated P,R
*Including
herpes
herpes simplex Any Rare
virus infection of burns,Severe
eczema 2<1

herpeticum, etc.
Laboratory Diagnosis of HSV Infections

Approach Test/comment
Direct microscopic examination of Tzanck smear shows multinucleated giant cells
cells from base of lesion and cowdry type A inclusion bodies

Cell culture HSV replicates and causes indentifiable CPE in


most cell cultures*
Assay of tissue biopsy, smear, or Enzyme immunoassay, immunofluorescent
vesicular fluid for HSV antigen or stain, in situ DNA probe analysis and PCR are
DNA used
HSV type distinction {HSV-1 vs. Type-specific antibody, DNA maps of restriction
HSV-2} enzyme, SDS-gel protein patterns, and DNA
probe analysis are used

Serology Serology is not useful except for primary


infection/ epidemiology
Cytopathic Effect of HSV in cell Positive immunofluorescence test for
culture: Note the ballooning of HSV antigen in epithelial cell.
cells. )Linda Stannard, University )Virology Laboratory, New-Yale
Haven Hospital(
of Cape Town, S.A.(
Herpes
Encephalitis
Management
At present, there are only a few indications of antiviral chemo-therapy, with the
high cost of antiviral drugs being a main consideration. Generally, antiviral
chemotherapy is indicated where the primary infection is especially severe,
where there is dissemination, where sight is threatened, and herpes simplex
encephalitis.
Acyclovir – this the drug of choice for most situations at present. It is available
in a number of formulations:-
• I.V. )HSV infection in normal and immunocompromised patients(
• Oral )treatment and long term suppression of mucocutaneous herpes and prophylaxis
of HSV in immunocompromised patients(
• Cream )HSV infection of the skin and mucous membranes(
• Ophthalmic ointment
Famciclovir and valacyclovir – oral only, more expensive than acyclovir.
Other older agents – e.g. idoxuridine, trifluorothymidine, Vidarabine )ara-A(.
• These agents are highly toxic and is suitable for topical use for opthalmic infection
only
Anti herpesviral drugs

Chemical structure of antiherpes, antiviral agents,


acyclovir (ACV), penciclovir (PCV), ganciclovir (GCV),
foscarnet (PFA), iodoxuridine (IDU), trifluorothymidine
(TFT), vidarabine (Ara-A), and sorivudine (SVD).
(Reprinted from ref. 172, with permission.) (From Fields
Virology, 4th ed, Knipe & Howley, eds, Lippincott
Williams & Wilkins, 2001, Fig. 15-1)
Resistance

TK
inactivating
mutations

Activation of Mutations of
DNA
polymerase
Acyclovir

Chain Termination
Mechanism of action of acyclovir

Inhibitors of the polymerization reaction of


herpesvirus DNA polymerase. (From Fields
Virology, 4th ed, Knipe & Howley, eds,
Lippincott Williams & Wilkins, 2001, Fig. 15-2)
FDA Approved Antiviral Treatments
for Herpesvirus Infections
)serious presentations(
>
.No vaccine available
Killed,subunit,vaccinia
.hybrid
Disabled infectious single
)cycle vaccine ( DISC
are beeing developed

Cidofovir, Adefovir
Varicella-Zoster Virus
VZV
Chickenpox – Varicella
Shingles – Zoster
Properties

• Belong to the alpha herpesvirus subfamily of herpesviruses*


• Double stranded DNA enveloped virus
• Genome size 125 kbp, long and short fragments with a total
of 2 isometric forms.
• One antigenic serotype only, although there is some cross
reaction with HSV.
• Replicates slower than HSV, in fewer types of cells
Epidemiology
• Primary varicella is an endemic disease. Varicella is one of the
classic diseases of childhood, with the highest prevalence
occurring in the 4 - 10 years old age group.
• Varicella is highly communicable, with an attack rate of 90% in
close contacts.
• Most people become infected before adulthood but 10% of
young adults remain susceptible.
• Herpes zoster, in contrast, occurs sporadically and evenly
throughout the year.
Characteristic skin rash of varicella in all
stages of Its evolution
Varicella-Chickenpox
• Primary infection results in varicella )chickenpox(
• Incubation period of 14-21 days
• Presents fever, lymphadadenopathy. a widespread vesicular rash.
• The features are so characteristic that a diagnosis can usually be made
on clinical grounds alone.
• Complications are rare but occurs more frequently and with greater
severity in adults and immunocompromised patients.
• Most common complication is secondary bacterial infection of the
vesicles.
• Severe complications which may be life threatening include viral
pneumonia, encephalititis, and haemorrhagic chickenpox.
Mechanism of spread of
VZV within the body
Shingles-Zoster
Herpes Zoster in Thoracic Dermatome
Herpes Zoster Ophthalmicus
Herpes Zoster (Shingles)

• Herpes Zoster mainly affect a single dermatome of the skin.


• It may occur at any age but the vast majority of patients are more than 50
years of age.
• The latent virus reactivates in a sensory ganglion and tracks down the
sensory nerve to the appropriate segment.
• There is a characteristic eruption of vesicles in the dermatome which is
often accompanied by intensive pain which may last for months
)postherpetic neuralgia(
• Herpes zoster affecting the eye and face may pose great problems.
• As with varicella, herpes zoster in a far greater problem in
immunocompromised patients in whom the reactivation occurs earlier in
life and multiple attacks occur as well as complications.
• Complications are rare and include encephalitis and disseminated herpes
zoster.
Disease Mechanism of VZV-summary
 Initial replication is in the respiratory tract.
 VZV infects epithelial cells and fibroblasts.
 VZV can form syncytia and spread directly from cell to cell.
 Virus is spread by viremia to skin and causes lesions in
successive crops.
 VZV can escape antibody clearance, and cell-mediated
immune response is essential to control infection.
Disseminated, life-threatening disease can occur in
immunocompromised people.
 Virus establishes latent infection of neurons, usually dorsal
root and cranial nerve ganglia.
 Herpes zoster may result from depression of cell-mediated
immunity and other mechanisms of viral activation.
Varicella-Zoster Latency
 Productive infection in epithelial cells of skin and mucosa tissues.
 The latency of VZV is maintained tightly. No. asymptomatic
shedding. Reactivation is triggered by declining immunity to the virus.
 Virus remains latent in sensory ganglia, in the satellite cells which
surround the neurons (endothelial and fibroblastic, resembling glia).
There is now a consensus that latent VZV resides predominantly
in ganglionic neurons with less frequent infection of non-
neuronal satellite cells
 Several copies of the viral genome and several species of RNA
transcripts, not equivalent to the HSV LATs, are detected. There is
considerable evidence to show that at least five viral genes are transcribed
during latency
 Upon reactivation, replication of the virus occurs in the satellite
cells as well as neurons throughout the ganglion causing severe
pain and lesions in the peripheral epidermal cells of the
corresponding dermatome.
Laboratory Diagnosis
The clinical presentations of varicella or zoster are so
characteristic that laboratory confirmation is rarely
required. Laboratory diagnosis is required only for
atypical presentations, particularly in the
immunocompromised.

.
VZV diagnosis
Cytology
Cowdry’s A type intra nuclear inclusion bodies
Antigen detection
)Skin lesions, respiratory specimens, organ biopsies(
Fluorescent antibody examination for membrane
)antigens( FAMA
Virus isolation
Human diploid fibroblasts-CPE similar to HSV but after
longer incubation periods. Viral antigens can be detected
earlier by IF or ELISA
Serology
Used for screening of immunity to VZV and documenting
VZV infection. IgM and Ab increase can be detected also
in zoster patients
Cytopathic Effect of VZV

Cytopathic Effect of VZV in cell culture: Note the ballooning of cells. )Coutesy of
Linda Stannard, University of Cape Town, S.A.(
Management
• Uncomplicated varicella is a self limited disease and requires no
specific treatment. However, acyclovir had been shown to accelerate
the resolution of the disease and is prescribed by some doctors.
• Acyclovir should be given promptly immunocompromised
individuals with varicella infection and normal individuals with
serious complications such as pneumonia and encephalitis.
• Herpes zoster in a healthy individual is not normally a cause for
concern. The main problem is the management of the postherpetic
neuralgia.
• Three drugs can be used for the treatment of herpes zoster: acyclovir,
valicyclovir, and famciclovir. There appears to be little difference in
efficacy between them.
FDA Approved Antiviral Treatments
for Herpesvirus Infections
)serious presentations(
Penciclovir

Cidofovir, Adefovir
Prevention
• Preventive measures should be considered for individuals at risk of
contracting severe varicella infection e.g. leukaemic children,
neonates, and pregnant women
• Where urgent protection is needed, passive immunization should be
given. Zoster immunoglobulin )ZIG( is the preparation of choice but it
is very expensive. Where ZIG is not available, HNIG should be given
instead.
• A live attenuated vaccine is available. There had been great
reluctance to use it in the past, especially in immunocompromised
individuals since the vaccine virus can become latent and reactivate
later on.
• However, recent data suggests that the vaccine is safe, even in
children with leukaemia provided that they are in remission.
• It is highly debatable whether universal vaccination should be
offered since chickenpox and shingles are normally mild diseases.
VZV Vaccine-
VARIVAX/MERCK
VARIVAX-varicella virus vaccine live
Varicella virus isolated from the blood of a 3 years old
Japanese boy in 1972 . Attenuated by growing it in
different human and animal host cells. 1995 approved
.by FDA

•Induces protective antibodies and CMI

•Adverse reactions to the vaccine were generally mild

•How long immunity lasts?

•Can the chickenpox vaccine cause shingles?


Cytomegalovirus
CMV

Cytomegalic Inclusion Disease


Infectious Mononucleosis
Post Transfusion Syndrome
Properties
• Belong to the betaherpesvirus subfamily of herpesviruses
• double stranded DNA enveloped virus
• Nucleocapsid 105 nm in diameter, 162 capsomers
• The largest genome. The structure of the genome of CMV
is similar to other herpesviruses, consisting of long and
short segments which may be orientated in either direction,
giving a total of 4 isomers.
• A large no. of proteins are encoded for, the precise
number is unknown.
• Contains RNA mRNAs within the virion
Key genes encoded by cytomegalovirus
(CMV) pertinent to viral pathogenicity
Gene Function

UL55 (glycoprotein B) Surface glycoprotein and major target for neutralizing


antibodies
UL833 (pp65) Major target for CD8 restricted cytotoxic lymphocytes.
Major virions structural proteins
US27, US28, UL33, UL75 G coupled receptor family members. US28 acts as a
promiscuous chemokine receptor
US2, US3, US6 and US11 Proteins involved in the downregulation of HLA class I
display on infected cells*
UL18 class I HLA homologue Binds b2-microglobulin and may
function as and NK decoy
UL146 CXC chemokine homologue able to chemoattract
neutrophils
UL97 Protein kinase essential for replication. Activates ganciclovir
to its monophosphate Site of action of the benzimidazole
classes of drugs
UL54 DNA polymerase. Site of action of antiviral Compounds
such as ganciclovir (triphosphate), acyclovir (triphosphate),
cidofovir (disphosphate), and foscarnet
Epidemiology
CMV is one of the most successful human pathogens, it can be
transmitted vertically or horizontally usually with little effect on the host.
Transmission may occur in utero, perinatally or postnatally. Once
infected, the person carries the virus for life which may be activated
from time to time, during which infectious virions appear in the urine
and the saliva.
Reactivation can also lead to vertical transmission. It is also possible for
people who have experienced primary infection to be reinfected with
another or the same strain of CMV, this reinfection does not differ
clinically from reactivation.
In developed countries with a high standard of hygiene, 40% of adolescents
are infected and ultimately 70% of the population is infected. In
developing countries, over 90% of people are ultimately infected.
Disease Mechanisms of CMV
 CMV is acquired from blood, tissue,and most body
secretions.
 CMV causes productive infection of epithelial and other
cells.
 CMV establishes latency in T cells, macrophages, and
other cells.
 Cell-mediated immunity is required for resolution and
contributes to symptoms. Antibody role is limited.
 Suppression of cell-mediated immunity allows recurrence
and severe presentation.
 CMV generally causes sub clinical infection
Cytomegalovirus Infections
Age or Route Disease caused by
Immunocompetence primary infection
Prenatal Transplacental Encephalitis, hepatitis,
thrombocytopenia Long-
term sequelae include brain
Nerve deafness,
retinopathy damage;
Perinatal Cervical secretions, Nil
Breast milk, saliva
Blood transfusion Pneumonitis, disseminated
disease
Any age Saliva or Sexual Intercourse Mononucleosis
Mononucleosis,hepatitis
Blood transfusion
Immunocompromised* Saliva, sex, organ graft Pneumonia,hepatiitis,
retinitis, encephalitis
myelitis, gastrointestinal
* Diseases shown occur less commonly after reactivation of a latent infection
disease

* Diseases shown occur less commonly after reactivation of a latent infection


Clinical Manifestations
• Congenital infection - may result in cytomegalic inclusion disease
• Perinatal infection - usually asymptomatic
• Postnatal infection - usually asymptomatic. However, in a minority
of cases, the syndrome of infectious mononucleosis may develop
which consists of fever, lymphadenopathy, and splenomegaly. The
heterophil antibody test is negative although atypical lymphocytes
may be found in the blood.
• Immunocompromised patients such as transplant recipients and
AIDS patients are prone to severe CMV disease such as pneumonitis,
retinitis, colitis, and encephalopathy.
• Reactivation or reinfection with CMV is usually asymptomatic
except in immunocompromised patients.
CMV
Congenital Infection
• Defined as the isolation of CMV from the saliva or urine within
3 weeks of birth.
• Commonest congenital viral infection, affects 0.3 - 1% of all live
births. The second most common cause of mental handicap after
Down's syndrome and is responsible for more cases of congenital
damage than rubella.
• Transmission to the fetus may occur following primary or
recurrent CMV infection. 40% chance of transmission to the fetus
following a primary infection.
• May be transmitted to the fetus during all stages of pregnancy.
• No evidence of teratogenecity, damage to the fetus results from
destruction of target cells once they are formed.
Cytomegalic Inclusion Disease

• CNS abnormalities - microcephaly, mental retardation, spasticity,


epilepsy, periventricular calcification.
• Eye - choroidoretinitis and optic atrophy
• Ear - sensorineural deafness
• Liver - hepatosplenomegaly and jaundice which is due to hepatitis.
• Lung - pneumonitis
• Heart - myocarditis
• Thrombocytopenic purpura, Haemolytic anaemia
• Late sequelae in individuals asymptomatic at birth - hearing
defects and reduced intelligence.
(Laboratory Diagnosis (1
• Direct detection
– biopsy specimens may be examined histologically for CMV
inclusion bodies ) enlarged cell that contains a dense,
central, “owl’s eye” basophilic intranuclear inclusion body(
or for the presence of CMV antigens. However, the
sensitivity may be low.
– The pp65 CMV antigenaemia test is now routinely used for
the rapid diagnosis of CMV infection in
immunocompromised patients.
– PCR for CMV-DNA is used in some centers but there may
be problems with interpretation.
CMV pp65 antigenaemia test

)Virology Laboratory, New-Yale Haven Hospital(


(Laboratory Diagnosis (2
• Virus Isolation
– conventional cell culture is regarded as gold standard but
requires up to 4 weeks for result.
– More useful are rapid culture methods such as the DEAFF
test which can provide a result in 24-48 hours.
• Serology
– the presence of CMV IgG antibody indicates past infection.
– The detection of IgM is indicative of primary infection
although it may also be found in immunocompromised
patients with reactivation.
Cytopathic Effect of CMV

)Courtesy of Linda Stannard, University of Cape Town, S.A.(


DEAFF test for CMV

)Virology Laboratory, New-Yale Haven Hospital(


Treatment
• Congenital infections - it is not usually possible to detect
congenital infection unless the mother has symptoms of
primary infection. If so, then the mother should be told of the
chances of her baby having cytomegalic inclusion disease and
perhaps offered the choice of an abortion.
• Perinatal and postnatal infection - it is usually not necessary
to treat such patients.
• Immunocompromised patients - it is necessary to make a
diagnosis of CMV infection early and give prompt antiviral
therapy. Anti-CMV agents in current use are ganciclovir,
forscarnet, and cidofovir.
Antiviral Drug therapies Approved by the
U.S. Food and Drug Administration
O
VIRUS ANTIVIRAL DRUG TRADE NAME N
HN
HSV Acyclovir Zovirax
H 2N N N
Adenosine arobinoside Vidarabine, Vira HO-
CH2 O
(Ara A) CH2 CH2

Iododeoxyuridine Stoxil (idoxurine)


Trifluorothymidine Viroptic (trifluridine)
VZV Valacylovir Valtrex
Famciclovir Famvir
CMV Ganciclovir Cytovene
O O Phosphonoformate Foscarnet, Foscavir
HO P C
OH
OH
Prevention
• No licensed vaccine is available. There is a candidate live
attenuated vaccine known as the Towne strain but there are concerns
about administering a live vaccine which could become latent and
reactivates.
• Prevention of CMV disease in transplant recipients is a very
complicated subject and varies from center to center. It may include
the following measures.
– Screening and matching the CMV status of the donor and
recipient
– Use of CMV negative blood for transfusions
– Administration of CMV immunoglobulin to seronegative
recipients prior to transplant
– Give antiviral agents such as acyclovir and ganciclovir
prophylactically.
Epstein-Barr Virus
EBV

Infectious Mononucleosis (Glandular Fever)


African Burkitt’s Lymphoma
Nasopharyngeal Carcinoma
Post Transplant Lymphoproliferative
(Epstein-Barr Virus (EBV
• Belong to the gammaherpesvirus subfamily of
herpesviruses
• Nucleocapsid 100 nm in diameter, with 162 capsomers
• Membrane is derived by budding of immature particles
through cell membrane and is required for infectivity.
• Genome is a linear double stranded DNA molecule with 172
kbp
• The viral genome does not normally integrate into the
cellular DNA but forms circular episomes which reside in
the nucleus.
• The genome is large enough to code for 100 - 200 proteins
but only a few have been identified.
Herpesviruses Genomes
size

kbp 125

kbp 152

kbp 186

kbp 229

kbp 162
Epidemiology
• Two epidemiological patterns are seen with EBV.
• In developed countries, 2 peaks of infection are seen :
the first in very young preschool children aged 1 - 6 and
the second in adolescents and young adults aged 14 - 20
Eventually 80-90% of adults are infected.
• In developing countries, infection occurs at a much
earlier age so that by the age of two, 90% of children are
seropositive.
• The virus is transmitted by contact with saliva, in
particularly through kissing.
Disease Association
1. Infectious Mononucleosis
2. Burkitt's lymphoma
3. Nasopharyngeal carcinoma
4. Hodgkin’s disease
5. Lymphoproliferative disease and lymphoma in the
immunosuppressed.
6. X-linked lymphoproliferative syndrome
7. Chronic infectious mononucleosis
8. Oral leukoplakia in AIDS patients
9. Chronic interstitial pneumonitis in AIDS patients.
Disease Mechanisms of EBV
 Virus in saliva initiates infection of oral epithelia and spreads
to B cells in lymphatic tissue.
 There is productive infection in epithelial cells.
 Virus promotes growth of B cells (immortalizes).
 T cells kill and limit B-cell outgrowth and promote latency in B
cells. They are required for controlling infection. Antibody
role is limited.
 T-cell response (lymphocytosis) contributes to symptoms of
infectious mononucleosis.
 There is causative association with lymphoma and leukemia
in T-cell-deficient people and African children living in malarial
regions (African Burkitt’s lymphoma) and with
nasopharyngeal carcinoma in China
Progression of EBV Infection

C3d-CD21

B cells are
semipermi
ssive

EBER 1,2
LMP-2A Latent infection

EBNA1 BL
Epstein-barr Virus Proteins Required for Establishment
and Maintenance of Latent Infection
Epstein-Barr Virus Functions
protein
EBNA-1 Maintains replication of the latent Epstein-Barr virus
genome.
EBNA-2 A transcription factor that coordinates Epstien-Barr virus
and cell gene expression in the latent infection.
EBNA-LP Required for cyclin D2 induction in primary B cells in
cooperation with EBNA-2.
EBNA-3A and EBNA-3C Play important roles early in establishment of the latent
infection
LMP-1 An integral membrane protein.
Stimulates the expression of several surface adhesion
molecules in B cells, a calcium-dependent protein kinase
and the apoptosis inhibitor Bcl-2.
LMP-2 An integral membrane protein required to block activation
of the src family signal transduction cascade; an inhibitor
of reactivation from latency.
Pathogenesis of EBV
Infectious Mononuclosis
• Primary EBV infection is usually subclinical in childhood. However
in adolescents and adults, there is a 50% chance that the syndrome of
infectious mononucleosis (IM) will develop.
• IM is usually a self-limited disease which consists of fever,
lymphadenopathy and splenomegaly. In some patients jaundice
may be seen which is due to hepatitis. Atypical lymphocytes are
present in the blood.
• Complications occur rarely but may be serious e.g. splenic rupture,
meningoencephalitis, pharyngeal obstruction and neurological
comlications, GB and miningoencephalitis.
• In some patients, chronic IM may occur where eventually the patient
dies of lymphoproliferative disease or lymphoma.
• Diagnosis of IM is usually made by the heterophil antibody test and/or
detection of EBV IgM.
• There is no specific treatment.
• EBV persists in memory B cells for lifetime and may be reactivated.
Atypical T-cell (Downey Cell) Characteristic
of Infectious Mononucleosis
Clinical Course of Infectious Mononucleosis and
Laboratory Findings of Those With the Infection

Clinical
Syndrome*

Labortory
Data
Time

Serological
Data
Immunocompromised Patients
• After primary infection, EBV maintains a steady low grade latent
infection in the body. Should the person become
immunocompromised, the virus will reactivate. In a few cases,
lymphoproliferative lesions and lymphoma may develop. These
lesions tend to be extranodal and in unusual sites such as the GI tract or
the CNS.
• Transplant recipients e.g. renal - EBV is associated with the
development of lymphoproliferative disease and lymphoma.
• AIDS patients - EBV is associated with oral leukoplakia and with
various Non-Hodgekin’s lymphoma.
• Ducan X-linked lymphoproliferative syndrome - this condition occurs
exclusively in males who had inherited a defective gene in the X-
chromosome, genetic defect in a T-cell gene )SLAM( preventing the T
cell from controlling B cell growth. . This condition accounts for half of
the fatal cases of IM.
Diagnosis
• Acute EBV infection is usually made by the heterophil antibody
( horse monospot test or ELISA) test and/or detection of anti-
EBV VCA IgM.
• Cases of Burkitt’s lymphoma should be diagnosed by histology.
The tumour can be stained with antibodies to lambda light chains
which should reveal a monoclonal tumour of B-cell origin. In
over 90% of cases, the cells express IgM at the cell surface.
• Cases of NPC should be diagnosed by histology.
• The determination of the titer of anti-EBV VCA IgA in screening
for early lesions of NPC and also for monitoring treatment.
• A patient with non-specific ENT symptoms who has elevated
titers of EBV IgA should be given a thorough examination.
Serological profile for EBV infections
IF ASSAYS-

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IgM Heterophile antibody recognizes the Paull-Bunnell antigen •


in sheep,horse and bovine RBCs
Vaccination
• A vaccine against EBV which prevents primary EBV infection
should be able to control both BL and NPC.
• Such a vaccine must be given early in life. Such a vaccine would
also be useful in seronegative organ transplant recipients and those
developing severe IM, such as the male offspring of X-linked
proliferative syndrome carriers.
• The vaccine should not preferably be a subunit vaccine since there
is a danger that a live vaccine may still have tumorigenic
properties.
• The antigen chosen for vaccine development is the MA antigen gp
340/220 as antibodies against this antigen are virus
neutralizing.
• This vaccine is being tried in Africa.